Dental insurance is a contract between your employer and a dental insurance company. The benefits you receive from your policy are based on the terms of the contract negotiated between your employer and the dental insurance company selected by your employer. In virtually all instances, dental insurance provides only a partial allowance for basic care and some other specified dental services.

Actually there are major differences between the two. One of the most significant differences lies in the amount of coverage you can count on. In the case of dental insurance, even the most comprehensive policy will never pay for all of the dental service you receive. Dental insurance is an allowance rather than a pay-all proposition.

Your dental plan is strictly a business relationship between your employer and the selected dental insurance company. The amount your plan pays is determined by the agreement negotiated by your employer with the insurer, and, of course, the negotiating parties have no knowledge of your dental needs. In most cases, the dental benefits you receive are mediated by your company's human resources representative and the dental insurance agent. Cost, not dental care, is always the prime consideration. ADA recommendations for basic care are not a significant factor in these bargaining sessions. Essentially, your dental coverage is determined not by your dental needs—but by how much your employer contributes to the plan. And like automobile insurance, there is always a deductible negotiated up front. No dental insurance company pays the whole cost.

The insurance company does. Typically, a dental insurance company will survey a geographical area and calculate an “average fee” for dental services within that area. Then, the company will take 80 percent of that fee amount and declare it “usual and customary.” Anything above that “usual and customary” figure must be paid by the patient. Insurance companies consider this to be the patient's co-payment.

Unfortunately, when insurance companies calculate the average fee for a geographical area, their calculations are based on the lowest common denominator for dental services. For instance, they include the lowest cost, lowest quality dental materials, and of course, they include the services provided by discount dental clinics and managed care facilities. As you would expect, a cosmetic dentistry practice normally will exceed the “usual and customary” fees established by dental insurance companies because only the highest quality materials are used.

A dental insurance program may provide a portion of the basic dental services recommended by the ADA . Because the costs of the benefits to be covered are negotiated up front by your employer and the dental insurance company, however, it is highly improbable that some dental services, especially those considered “cosmetic” in nature, will be included in the plan. As noted earlier, the selection of those services that will be included or excluded from your plan has nothing to do with your particular dental needs, nor with the basic standards recommended by the ADA . The goal of the dental insurance company is to provide only benefits that have been negotiated with your employer for specifically selected services. These benefits are viewed as an “allowance” toward your dental care.

The disparity between personalized cosmetic dentistry services and the services covered by dental insurance is large, and growing larger every day. One dramatic example can be found in the comparison of old fashioned mercury fillings (covered by insurance) and the longer lasting, tooth colored fillings (not covered by insurance) which I have used since 1997. Tooth colored fillings that are chemically bonded to your teeth are superior in every way, but you probably won't find them in your dental insurance policy. (Most insurance programs automatically re-code them to the discounted mercury fillings.) It's ironic that the California legislature has passed legislation to make it illegal for dentists to use mercury fillings after 2007. Apparently, legislators determined that “old line” dentists would need the extra five years to bring their skills up to the new standard. And dental insurance companies will soon have to update their definition of “usual and customary” services—or find themselves in defiance of the law.

They most certainly do. I am a cosmetic dentist, and what I do is implied in those two descriptive words. I help people obtain the smile they want. I help people improve their appearance—and in virtually every instance, their self-image and outlook on life—by giving them beautiful, healthy smiles. I've studied all my adult life to become expert at what I do. I use the most advanced, state-of-the-art dental technology, and I use the skills I have honed for 27 years to help my patients achieve a level of satisfaction they never thought attainable. This is my goal with every patient who walks into my office. On the other side of the coin, the goal of the dental insurance company, as indicated earlier, is to provide only the negotiated benefits for specifically selected dental services. Yes, it's fair to say that we have very different objectives, and our differences have become so great in recent years that they threaten to make dental insurance obsolete.

The restrictive practices of the dental insurance industry have generated a serious backlash from dentists in Colorado and across the nation. In fact, the animosity between dentists and insurers has now reached the point that growing numbers of dentists are dropping insurance programs altogether. Currently, 44 percent of Colorado dentists do NOT participate in discounted insurance programs. And, in a sign of support for the integrity of the dental profession, the American Dental Association has announced that it is considering a class action suit against the insurance industry for restraint of trade.

Obviously, I do not wish to compromise a patient's dental care based upon restraints placed on that care by the patient's dental insurance company. My staff will do everything possible to help patients understand and make the most of their dental insurance benefits. Of course, regardless of the insurance coverage a patient has, financial arrangements must be made directly with us prior to treatment. We provide all the required information and forms necessary for patients to file their insurance claims and to receive any benefits that are available to them.

Ron VanWechel, DDS